Across England, 344 never-events happened, with
wrong-site surgery making up 138 of them.
Examples of sentinel event alerts include alerts about preventing
wrong-site surgery, safe use of opioids, preventing medication errors, preventing violence, and preventing infections.
The term "Never Event" was first used in 2001 in reference to alarming events, such as
wrong-site surgery. Since then, the list (3) of "Never Events" has increased to identify adverse events that fall into three categories:
Operating room briefings and
wrong-site surgery. J Am Coll Surg.
(16) The Joint Commission has identified factors that may enhance the risk of
wrong-site surgery: multiple surgeons involved in the case, multiple procedures during a single surgical visit, unusual time pressures to start or complete the surgery, and unusual physical characteristics including morbid obesity or physical deformity.
Prevention of MEs such as
wrong-site surgery, medication errors, and patient falls are important issues for PS practices in the OR.
Wrong-site surgery is a frequent problem for dermatologists.
(3) Specific clinical interventions are needed to reduce
wrong-site surgery (WSS), including wrong- site tooth extraction which is a rare but potentially disastrous clinical error.
The report also includes details of a
wrong-site surgery case in July 2011 where a surgeon started operating on the wrong tooth during dental extraction.
He covers principles of medical malpractice; errors, incidents, and complications in general surgery; retained surgical foreign bodies; quality management related to
wrong-site surgery; towards a preventative safety culture within the hospital; and ethical aspects of an open safety culture: towards a new physician-patient relationship in 21st-century medicine.
wrong-site surgery - a surgical operation performed on the wrong part of the body